Wound Care Essentials
BEFORE YOU OPEN ANY EXPENSIVE WOUND CARE PRODUCTS:
THE FIVE ESSENTIALS OF WOUND CARE PRACTICE
By the time a patient finds themselves in the exam room of a wound care physician, they are likely to be suffering certain ailments or conditions that prevent normal wound healing. Whether they have diabetes, peripheral vascular disease, or a chronic infection, they may not respond to standard wound care practices; they may need one of the currently available advanced wound care modalities. These include all sorts of bio-engineered tissue grafts derived from such varied sources as human placenta and nanotechnology. These products can be quite expensive and tricky to obtain reimbursement for, but such products can be the difference determining whether a wound heals or not. So before opening any $1000 boxes, the prudent wound care practitioner needs to explore and address 5 important considerations.
Blood Flow – The primary consideration for effective wound healing is vascular status. The delivery of oxygenated blood to the wound site is necessary for tissue growth and wound closure, and without it, hope of healing is dim. Ways to assess adequate blood flow include inspection of skin quality, moisture and turgor; temperature, warm not hot; and hair growth. Feel for pulses and locate and listen for pulsatile blood flow with a hand-held Doppler. If poor circulation is suspected, then advanced imaging including ABI’s, arterial Dopplers and CT angiography may indicate the presence and severity of vascular pathology. Also, transcutaneous oxygen measurements are helpful.
Blood Sugar – Diabetes Mellitus is probably the single most important disease process responsible for creating chronic wounds. This disease affects the microvasculature and the chemical environment within cells inhibiting their viability and regeneration. Readings from a glucose meter should generally remain consistent below 180 mg/dl. Testing times should vary throughout the day to discover any insidious spikes in blood sugar. Hemoglobin A1C values should stay below 7.5, as a general guideline. If blood glucose is high, then communication with the primary care provider may be necessary to initiate a more effective glucose lowering regimen.
Bio-burden – This consideration is two-fold: it involves both the necrotic, non-viable tissue on a wound, and the pathogenic microorganisms, including bacteria, virus, and fungi that colonize, infect, and form bio-films on wounds. Bio-burden and its’ management is largely the domain of the wound care practitioner. Frequent sharp debridement of necrotic and fibrotic tissue promotes angiogenesis and growth of pristine tissue. Effective antimicrobial therapy requires identification of pathogens and pointed selection of cleansers, antibiotics, and dressings. A consult to an infectious disease physician may be helpful in cases of antibiotic allergy or polypharmacy.
Nutritional Status – The medicinal power of food is often under-emphasized. Protein and lipid are the building blocks of the body and are necessary for the anabolic (tissue building) processes of wound healing. Lab values of albumin greater than 3.5 are indicative of good protein nutrition. Suggesting protein supplementation and consultation with a dietitian can address this key component of wound care.
Pressure – All ulcers of the integument involve pressure as a contributing factor. Shear forces and weight bearing pressure can halt all wound healing progress despite perfect adherence to all the aforementioned wound care principles. Total contact casting is the gold-standard therapy for offloading foot wounds, but removable casts, offloading appliances and dressings may be more tolerable. A certified orthotist or pedorthist can be helpful in offloading wounds.
Among circulation, blood sugar, bio-burden, nutrition and pressure, which is the most important? The most important factor in wound healing is the one that is not being addressed. These factors represent a basis for standard wound care. The advances in leading edge wound care products is exciting and dizzying at the same time, and the results of their use is compelling and well documented; but excellent results won’t be realized unless basic comprehensive wound care practices are performed.